DIRECTOR OF COMPLIANCE

Description

ORGANIZATION

The mission of Ravenswood Family Health Network (RFHN) is to improve the health of the community by providing culturally sensitive, integrated primary and preventative health care to all, regardless of ability to pay or immigration status, and collaborating with community partners to address the social determinants of health.

POSITION SUMMARY  

Under the administrative direction of the Chief Executive Officer (CEO), and in collaboration with the Executive Team, the Director of Compliance (DOC) is responsible for overseeing and monitoring RFHN's compliance, privacy and risk management and patient experience programs. The DOC also has oversight of contract administration.

The position ensures that the Board of Directors, management and employees are all in compliance with the rules and regulations of regulatory agencies; that company policies and procedures are followed, and that behavior in the organization meets the company's Standards of Conduct. Compliance monitoring responsibilities of federal, state, county and other regulatory expectations include, but are not limited to: clinic licensing and certification, HIPAA/HITECH, CMS, OSHPD, OSHA, Health Resources Service Administration (HRSA) and the Bureau of Primary Health Care (BPHC), Health Plan of San Mateo (HPSM) and other health plans, CDC, Vaccines for Children (VFC), and the San Mateo County Health Department.

The Director of Compliance is a member of the Executive Management Team and in their compliance role, directly reports to the Board of Directors’ Compliance and Risk Committee.  As part of their compliance and risk management functions, they will perform patient chart audits together with RFHN staff and/or consultants to assess individual and organizational compliance with RFHN policies and procedures. The position oversees facility licensing compliance, including CLIA, retail pharmacy license, and staff credentialing. This position is a member of the administrative team supporting NCQA's Patient-Centered Medical Home standards and practices.

DUTIES AND RESPONSIBILITIES

To be performed in accordance with RFHN Policies and Procedures

Compliance

1. Develops, initiates, maintains, and revises compliance policies and procedures for the operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct.
2. Establishes and provides direction and management of the Compliance Hotline. Reviews monthly Compliance Hotline reports to evaluate results and trends, review specific reports, and coordinate case management of incidents if necessary. Provides training to all new staff to report suspected fraud and other improprieties to the hotline without fear of retaliation.

1. Designs, coordinates, conducts and/or oversees investigations on matters related to compliance (e.g. respond to the incident reports, Compliance Hotline calls, or suspected violations). Prepare written reports of investigations with recommendations for corrective action for the Board of Directors, CEO, CMO, Director of Clinical Operations and department managers, as appropriate.
2. Develops and coordinates annual internal compliance review and monitoring activities, including periodic departmental and medical records reviews for compliance in medical record documentation, coordination and continuity of care, health prevention, site personnel qualifications and training as it relates to scope of practice, HIPAA, office management practices and other areas as specified by licensing and external regulatory agencies. Develops recommendations for corrective action based on review findings. Follows up on reviews to verify that corrective actions have been implemented.
3. Ensures compliance with HIPAA privacy practices, HITECH Security provisions and promotes activities and education to foster information privacy awareness within the organization.
4. Reviews organizational policies and procedures to ensure compliance with legal, accreditation, and internal standards. Analyzes existing policies, identify gaps and recommend new/revised policies and procedures, approval processes, and monitoring methods for departmental use. Reviews detailed departmental processes and policies and document deficiencies.
5. Presents new or revised policies and procedures to Board of Directors for approval.
6. Serves as organizational liaison for clinic licensing and certification, HRSA, CMS, HSPM, VFC, CHDP, CDP, VHP, SCFHP, San Mateo County Health Department, and other external agency audits.
7. Presents external audit reports to CEO and Compliance Steering Committee and/or appropriate members of the Executive team as appropriate and oversees development of and adherence to a corrective action plan for any identified deficiencies.

Risk Management

As the health center's Risk Officer, this position performs a variety of duties related to managing potential risks and liabilities within RFHN facilities and in RFHN personnel work performance, by creating and implementing policies that improve both patient care and employee safety. The Risk Officer conducts periodic risk assessments and educates and trains providers and staff on potential risks and how to avoid or mitigate them. The position also works with the health center's legal counsel and insurers in situations of medical malpractice or workers' compensation claims. The position does not provide direct patient care services, but, typically, the Risk Officer's time is split between administrative offices and clinic areas. The position interacts with patients, employees, clinic administrators, vendors, and external inspectors and auditors, and is capable of resolving escalated issues arising from operations and requiring coordination with other departments and/or leadership.

1. Reviews and maintains log of all patient experience and incident reports. Reports trends and sentinel events to the Board Compliance and Risk Committee on a quarterly basis.
2. Monitors Patient Experience Hotline and log calls on a daily basis.
3. Investigates matters related to complaints and incidents, including conducting internal investigations (e.g. responding to patient experience reports, Ravenswood Cares form, and patient experience hotline calls).
4. Prepares written reports of the investigation with recommendations for corrective action for the CEO, CMO, Clinical Operations Director and/or department managers.
5. Analyzes patient experience and incident report logs and sentinel events to identify areas for improvement. Prioritizes issues in risk assessment based on level of organizational exposure. Presents investigative findings and recommendations to the Clinical Quality Management (CQM) Team.
6. Reports incidents resulting in patient injury to NorCal the (FTCA) Intermediary for HRSA as necessary.
7. Manages and processes claims-related incidents and serves as the health system's claims point of contact.
8. Oversees ergonomic risk management to reduce employee work related injuries.
9. Reports any unusual or recurring patient care issues that arise from the survey results to the CEO, CQM Team, Compliance Steering Committee and/or Board Compliance and Risk Committee, as appropriate.

General Agency Duties 

1. Ability to motivate a diverse group of individuals towards accomplishing common goals and objectives.
2. Maintains up-to-date job knowledge through professional reading, conference and seminar attendance.
3. Attends RFHN staff retreats and Board of Directors meetings, as requested by the Chief Executive Officer.
4. Represents RFHN in a positive light to patients, the community and other agencies.
5. Fosters an environment that promotes trust and cooperation among patients and staff; maintains strictest confidentiality concerning all patient and employee information. 
6. Promotes and exemplifies in action, the mission, goals, policies, procedures and principles of RFHN to supervisees and other clinic staff.
7. Participates in outreach activities, agency advocacy, and serves on ad hoc committees, as requested.
8. Performs other duties as assigned and requested.

Qualifications

QUALIFICATIONS

• Certified in Healthcare Compliance (CHC).
• Certified in Healthcare Privacy Compliance (CHPC).
• Certified Professional in Healthcare Risk Management (CPHRM), highly desirable.
• Masters or higher degree from an accredited college or university in public health, health administration, business administration, public policy or related field.
• Minimum 5 years senior compliance management experience in an ambulatory health care services environment.
• Bachelor’s degree with two additional years of senior compliance management experience
• Familiarity with Stark Law, False Claims Act, HIPAA/HITECH, Anti-Kick Back Statute, Compliance oversight, Corporate Integrity Agreements (CIA), Medicare/Medicaid & 340B Programs, Investigations, Health Plan Contracts, Patient Satisfaction, Staff Compliance Training, Monitoring and Auditing.
• Skill in Project Management, Physician Relations, Contract Management, Problem Resolution, Continuous Improvement, Relationship Building.
• Computer literate in a PC Environment.
• Excellent verbal and written communication skills.
• Flexible, able to respond to incidents based on urgency and priority, multitask oriented.
• Ability to work independently and collaboratively in a multicultural and ethnically diverse population.
• Current California Driver's License in good standing, a personally owned, currently insured vehicle to drive on work related business.
• Up to date with COVID-19 vaccines per current CDC guidelines strongly recommended.

The salary range for this position is $180,000 to $220,000 annually.  However, the final base salary will be determined upon a number of individualized factors such as (but not limited to) the scope and responsibilities of the position, job-related knowledge, skills, experience, education and certification levels, and departmental budget. We also consider internal equity with our current employees when making final offers.

Ravenswood Family Health Network is an equal opportunity employer.

Salary : $180,000 - $220,000